Healthcare Provider Details

I. General information

NPI: 1053721480
Provider Name (Legal Business Name): JONATHAN CULLIS PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 CONESTOGA DR
SPRINGFIELD IL
62711-7962
US

IV. Provider business mailing address

57 PROVIDENCE LN
SPRINGFIELD IL
62711
US

V. Phone/Fax

Practice location:
  • Phone: 217-547-2410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number051.297101
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: